The noise of the ice rubbing against the hull likely prevented the deckhand from hearing anything, as he was in the hold when the bosun fell. The deckhand searched almost everywhere on the vessel except in the area of No.1 hold. The repairs were done in the opposite corner of the hold from where the injured man was found; the crew members' attention was focused on that location. In addition to a lack of lighting, the injured was wearing dark-coloured clothing, and this caused a delay in finding him. Although the exact cause of the fall could not be determined, certain factors provide a basis for different scenarios that could account for the fatal fall. The vessel was heading north-east in a north-west wind of about 15 knots. The cabin housing the crane controls is opened by pulling the door from right to left. As there was no railing on the running board, it is possible that the wind caught the crane door when the bosun opened it, causing him to lose his balance and fall. The electric drive motor was not turned on, indicating that the bosun probably had not entered the operator's cabin of No.1 crane. A second possibility is that the bosun bent over the coaming to look at the bottom of the hold. The ice and snow at the aft starboard corner of the hatchway could have contributed to his falling over the coaming; it is also noted that this location is directly above the place where the injured bosun was found. No traces of oil or other products were found on the deck which could have caused a person to fall or lose their balance near the hold. The soles of the fur boots worn by the bosun could not be examined. The body was transported to the Centre hospitalier du Grand Portage at Rivire-du-Loup, Quebec. From there, the Quebec Coroner took custody of the body and performed an autopsy. The forensic report indicated that the primary cause of death was severe cerebral trauma accompanied by fractures of the cranium. The bosun was in good physical condition, was not taking medication, did not drink alcohol, and was well liked by his co-workers. He had a medical examination on 13July 1994 and was issued a medical certificate valid for 12months. The bosun had been on board the vessel for one month and, according to his colleagues, he did not seem depressed or troubled. Modifications were made to the crane during the days following the tragic accident. The running board was enlarged and a railing was installed on the platform in front of the crane cabin. These repairs were made following a notice issued by the Canadian Coast Guard on 11March 1995 which directed that improvements be made to provide safer access to the crane cabin.Analysis The noise of the ice rubbing against the hull likely prevented the deckhand from hearing anything, as he was in the hold when the bosun fell. The deckhand searched almost everywhere on the vessel except in the area of No.1 hold. The repairs were done in the opposite corner of the hold from where the injured man was found; the crew members' attention was focused on that location. In addition to a lack of lighting, the injured was wearing dark-coloured clothing, and this caused a delay in finding him. Although the exact cause of the fall could not be determined, certain factors provide a basis for different scenarios that could account for the fatal fall. The vessel was heading north-east in a north-west wind of about 15 knots. The cabin housing the crane controls is opened by pulling the door from right to left. As there was no railing on the running board, it is possible that the wind caught the crane door when the bosun opened it, causing him to lose his balance and fall. The electric drive motor was not turned on, indicating that the bosun probably had not entered the operator's cabin of No.1 crane. A second possibility is that the bosun bent over the coaming to look at the bottom of the hold. The ice and snow at the aft starboard corner of the hatchway could have contributed to his falling over the coaming; it is also noted that this location is directly above the place where the injured bosun was found. No traces of oil or other products were found on the deck which could have caused a person to fall or lose their balance near the hold. The soles of the fur boots worn by the bosun could not be examined. The body was transported to the Centre hospitalier du Grand Portage at Rivire-du-Loup, Quebec. From there, the Quebec Coroner took custody of the body and performed an autopsy. The forensic report indicated that the primary cause of death was severe cerebral trauma accompanied by fractures of the cranium. The bosun was in good physical condition, was not taking medication, did not drink alcohol, and was well liked by his co-workers. He had a medical examination on 13July 1994 and was issued a medical certificate valid for 12months. The bosun had been on board the vessel for one month and, according to his colleagues, he did not seem depressed or troubled. Modifications were made to the crane during the days following the tragic accident. The running board was enlarged and a railing was installed on the platform in front of the crane cabin. These repairs were made following a notice issued by the Canadian Coast Guard on 11March 1995 which directed that improvements be made to provide safer access to the crane cabin. The running board in front of the crane was not fitted with a railing. There was snow and ice on the raised deck aft and to starboard of the hatchway. No one witnessed the bosun's fall. The deckhand did not report the disappearance of the bosun before retiring to his cabin. The bosun did not receive first aid for about one hour after he fell. The bosun was unable to inform his rescuers of the cause of his fall. Repairs were made to provide safer access to the crane.Findings The running board in front of the crane was not fitted with a railing. There was snow and ice on the raised deck aft and to starboard of the hatchway. No one witnessed the bosun's fall. The deckhand did not report the disappearance of the bosun before retiring to his cabin. The bosun did not receive first aid for about one hour after he fell. The bosun was unable to inform his rescuers of the cause of his fall. Repairs were made to provide safer access to the crane. The cause of the fall and the location where the bosun lost his footing on the SANTIAGO DE CUBA are still unknown. As the bosun was not found right away and his disappearance was not reported, the injured man did not receive first aid immediately.Causes and Contributing Factors The cause of the fall and the location where the bosun lost his footing on the SANTIAGO DE CUBA are still unknown. As the bosun was not found right away and his disappearance was not reported, the injured man did not receive first aid immediately.